Model - HWC(wheelchair) _______           Model - HWB (bucket seat)_______
Cash_____ Personal Finance_____Certified Check_____ G.A.T.E. Program_____
Colors:Red__ Blue__ Black__ Green__ Yellow__ Brown__
Standard Equipment Includes:Removable roof with sky light, wind shield, stereo, dash gauges, tie downs/ seat belts, black leather rear bench seat, steel belted tires and mag wheels, spare rear tire w/ jack stand, and tool kit

Name:____________________________________________Date: __-__-____
Address:____________________________________
City:__________________ State:______________ Zip Code:__________
Phone#: (___)___-____ Email:_______________________________________
Valid Drivers License:YES __ NO __ M/C Endorsment:YES __ NO __
Type of Disability: ________________________________________________
Manual Wheelchair:Brand/Style______________________________________
Electric Wheelchair:Brand/Style______________________________________
Independence level rating:Good__ Fair__ Need a little help__

Nature of Fund Raisers for G.A.T.E. Participant/Date of Fund Raisers
___________________________________________________________________
___________________________________________________________________
I agree to abide and follow B.M.F. LLC. Program Guidelines to the receipt of a Brand New Custom Built V-Twin CHARIOT-R-TRIKE©. To pre-pay in full, or return all fundraiser proceeds (less expenses) to a special sealed account in my name until funds reach or exceed vehicle cost. I promise below not to hold B.M.F. LLC. liable in any way, shape or claim now, or in the future. This document is true and complete and being submitted by myself for approval with my legal notorized signiture below.

Signature _____________________________ Valid Notory Seal Promise